Beyond the Symptoms

Reducing Emergency Department Overutilization by Broadening Homelessness Services

Luke Morris

Cedars-Sinai Medical Center

AGENDA

  • Homelessness Figures

  • The ED Care Model

  • Problems at the Intersection

  • A New Role

  • Evidence of Effect

This author has no conflicts of interest to disclose

Homelessness by the Numbers

  • United States (~pop. 331.5 million)

    • 580,466 People Experiencing Homelessness (PEH)

    • 0.175% of U.S. population

     

  • California (~pop. 40 million)

    • 161,548 PEH

    • 0.408% of state population

    • California makes up 11.9% of U.S. pop, but hosts 28% of all PEH in U.S.

Figures via 2020 Census and HUD 2020 Annual Homelessness Assessment Report

Homelessness in LA

  • LA County (~pop. 10 million)

    • 25% of California’s population but 41% of its PEH

    • 3% of U.S. population but 12% of its PEH

 

  • LA City (~pop. 3.9 million)

    • 39% of county population by 62% of PEH

    • 2/3 in first episode of homelessness

    • Estimated new 20,000 PEH amid COVID

Figures via LAHSA 2020 Count and Union Rescue Mission in Skid Row

The Emergency Medicine Model

  • A place for stabilization

    • Get you stable enough to go back home

    • or stable enough to transport to an inpatient unit

 

  • Problems with non-urgent utilization

    • Overburdens department resources

    • Increases wait for care for all patients

    • Chair reaction of patients Leaving before they’re even seen

Packed EDs

  • Crowding and overflowing longstanding issues

  • Examples of low-acuity cases coming in

    • prescription refills

    • treatment of hypertension

    • chronic elevated blood sugar

    • behavioral health

  • Source of patient and staff harm

  • “COVID-19 has laid bare medicine’s house of cards.” *

* Dr. Sharon Anoush Chekijian in U.S. News and World Report | Graphic via CDC

Homeless Care at Cedars-Sinai ED

  • 7,956 visits by 3,194 PEH patients Feb 2020-Jan 2021

  • Roughly 2.49 visits per PEH patient

  • Many there for basic needs

    • Food

    • Shelter

    • Primary care-level treatment

California SB1152

  • Passed in 2018, requires hospitals to document info about patients experiencing homelessness before discharging them.

    • Services offered

      • Transportation

      • Meal

      • Meds

      • Vaccinations

      • Weather-appropriate clothing

    • Resources offered

      • Clinical/Behavioral

      • Follow-up with PCP

      • Help getting health coverage

A New Role is Born

Community Resource Coordinator

  • Responsible for SB1152 checklist items

  • Help PEH patients find more sustainable support

  • Provide connections to community resources

    • Shelter

    • Staple needs

    • Insurance

    • Follow-up & specialty care appointments

How’s It Going?

Are CRCs effective at reducing the use of emergency services for non-urgent matters while ensuring that homeless patients can access their basic needs?

 

Data gathered in fulfilling SB1152 needs used to measure role’s impact

Studying the Impact

  • Diff-in-diff cohort model

    • Visit rates of patients experiencing homelessness

    • Split by whether they were seen by a CRC during their index visit

  • Dependent variables

    • Time interval between visits (in days)

    • Cost of stay

    • Length of stay (LOS)

  • Differences in the populations were tested for statistical significance using a Welch’s t-test

What We Found

  • A two-sample t-test demonstrated statistical significance (p = 0.0014)

  • 22.82% increase to # of days elapsed before a patient returned to the ED after visiting with a CRC

  • 95% confidence interval: 2.6-10.9 days larger gap between ED visits

90-Day Return Rate

Revisit rate:

⬇️35%

95% CI:

0.8-1.4 fewer visits

p: <0.0001

180-Day Return Rate

Revisit rate:

⬇️35%

95% CI:

1.1-2.1 fewer visits

p: <0.0001

Other Results

  • Difference in cost of care

    • p = 0.1050

    • Not statistically significant

  • Difference in length of stay in the ED

    • p = 0.0150

    • Not statistically significant

  • Makes sense considering CRC can’t really affect those figures

Understanding the Results

  • Increased gap between ED visits

  • Lowered rate of ED visits over 90 and 180 days

  • Implications

    • Increased utilization of community resources may be decreasing frequency of needs that draw patients experiencing homelessness to ED

    • Reduced burden by lower-urgency needs on ED resources

  • Possible effects

  • Shorter wait times

  • Fewer patients leaving without being seen

  • Greater focus on other patients with more acute needs

Beyond the First Year …

  • Slides so far showed Feb 2020-Jan 2021, but the work continues.

  • Results Feb 2020-Jun 2022

    • 16,166 visits by 14,161 PEH patients

Overall Avg Gap Between Visits

⬆️ by 5.2-16.6 days

90-Day Visit Rate

⬇️ by 0.7-1.2 visits

180-day Visit Rate

⬇️ by 1.0-1.8 visits

.

Thank you

 

luke.morris@cshs.org

 

morrisLuke

 

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